<!-- https://idmanager.its.utexas.edu/eid_self_help/ -->
<form id="personalInfo" method="post" action="./">
  <fieldset>
    <p>
      <label for="firstName"><span>*</span>First (Given) Name:</label> <input type="hidden" name="qwicap-page-id" value="D41F428A46D78104" /><input type="hidden" name="qwicap-form-id" value="9EC0EC3CD02FF862" /><input type="text" id="firstName" name="firstName" size="25" />
    </p>
    <p>
      <label for="middleName">Middle Name:</label> <input type="text" id="middleName" name="middleName" size="25" />
    </p>
    <p>
      <label for="lastName"><span>*</span>Last (Family) Name:</label> <input type="text" id="lastName" name="lastName" size="25" />
    </p>
    <p>
      <label for="suffix">Generational Suffix:</label> <select name="suffix" id="suffix">
        <option value="">
          None
        </option>
        <option value="Jr">
          Jr.
        </option>
        <option value="Sr">
          Sr.
        </option>
        <option value="I">
          I
        </option>
        <option value="II">
          II
        </option>
        <option value="III">
          III
        </option>
        <option value="IV">
          IV
        </option>
      </select>
    </p>
    <p id="otherFName0">
      <label for="otherFirstName">Other First Names:<br />
      <span>(For example, your nickname.)</span></label> <input type="text" id="otherFirstName" name="otherFirstName" size="25" /> <input id="moreFirstNamesAdd" type="submit" value="+" name="moreFirstNames" />
    </p>
    <p id="otherLName0">
      <label for="otherLastName">Other Last Names:<br />
      <span>(For example, your maiden name.)</span></label> <input type="text" id="otherLastName" name="otherLastName" size="25" /> <input id="moreLastNamesAdd" type="submit" value="+" name="moreLastNames" />
    </p>
    <p>
      <label><span>*</span>Date of Birth:</label> <label id="month" for="monthOfBirth">Month:</label> <select id="monthOfBirth" name="monthOfBirth">
        <option value="-">
          --
        </option>
        <option value="01">
          Jan
        </option>
        <option value="02">
          Feb
        </option>
        <option value="03">
          Mar
        </option>
        <option value="04">
          Apr
        </option>
        <option value="05">
          May
        </option>
        <option value="06">
          Jun
        </option>
        <option value="07">
          Jul
        </option>
        <option value="08">
          Aug
        </option>
        <option value="09">
          Sep
        </option>
        <option value="10">
          Oct
        </option>
        <option value="11">
          Nov
        </option>
        <option value="12">
          Dec
        </option>
      </select> <label for="dayOfBirth" id="day">Day:</label> <select id="dayOfBirth" name="dayOfBirth">
        <option value="-">
          --
        </option>
        <option value="1">
          1
        </option>
        <option value="2">
          2
        </option>
        <option value="3">
          3
        </option>
        <option value="4">
          4
        </option>
        <option value="5">
          5
        </option>
        <option value="6">
          6
        </option>
        <option value="7">
          7
        </option>
        <option value="8">
          8
        </option>
        <option value="9">
          9
        </option>
        <option value="10">
          10
        </option>
        <option value="11">
          11
        </option>
        <option value="12">
          12
        </option>
        <option value="13">
          13
        </option>
        <option value="14">
          14
        </option>
        <option value="15">
          15
        </option>
        <option value="16">
          16
        </option>
        <option value="17">
          17
        </option>
        <option value="18">
          18
        </option>
        <option value="19">
          19
        </option>
        <option value="20">
          20
        </option>
        <option value="21">
          21
        </option>
        <option value="22">
          22
        </option>
        <option value="23">
          23
        </option>
        <option value="24">
          24
        </option>
        <option value="25">
          25
        </option>
        <option value="26">
          26
        </option>
        <option value="27">
          27
        </option>
        <option value="28">
          28
        </option>
        <option value="29">
          29
        </option>
        <option value="30">
          30
        </option>
        <option value="31">
          31
        </option>
      </select> <label id="year" for="yearOfBirth">Year:</label> <select id="yearOfBirth" name="yearOfBirth">
        <option value="-">
          --
        </option>
        <option value="1997">
          1997
        </option>
        <option value="1996">
          1996
        </option>
        <option value="1995">
          1995
        </option>
        <option value="1994">
          1994
        </option>
        <option value="1993">
          1993
        </option>
        <option value="1992">
          1992
        </option>
        <option value="1991">
          1991
        </option>
        <option value="1990">
          1990
        </option>
        <option value="1989">
          1989
        </option>
        <option value="1988">
          1988
        </option>
        <option value="1987">
          1987
        </option>
        <option value="1986">
          1986
        </option>
        <option value="1985">
          1985
        </option>
        <option value="1984">
          1984
        </option>
        <option value="1983">
          1983
        </option>
        <option value="1982">
          1982
        </option>
        <option value="1981">
          1981
        </option>
        <option value="1980">
          1980
        </option>
        <option value="1979">
          1979
        </option>
        <option value="1978">
          1978
        </option>
        <option value="1977">
          1977
        </option>
        <option value="1976">
          1976
        </option>
        <option value="1975">
          1975
        </option>
        <option value="1974">
          1974
        </option>
        <option value="1973">
          1973
        </option>
        <option value="1972">
          1972
        </option>
        <option value="1971">
          1971
        </option>
        <option value="1970">
          1970
        </option>
        <option value="1969">
          1969
        </option>
        <option value="1968">
          1968
        </option>
        <option value="1967">
          1967
        </option>
        <option value="1966">
          1966
        </option>
        <option value="1965">
          1965
        </option>
        <option value="1964">
          1964
        </option>
        <option value="1963">
          1963
        </option>
        <option value="1962">
          1962
        </option>
        <option value="1961">
          1961
        </option>
        <option value="1960">
          1960
        </option>
        <option value="1959">
          1959
        </option>
        <option value="1958">
          1958
        </option>
        <option value="1957">
          1957
        </option>
        <option value="1956">
          1956
        </option>
        <option value="1955">
          1955
        </option>
        <option value="1954">
          1954
        </option>
        <option value="1953">
          1953
        </option>
        <option value="1952">
          1952
        </option>
        <option value="1951">
          1951
        </option>
        <option value="1950">
          1950
        </option>
        <option value="1949">
          1949
        </option>
        <option value="1948">
          1948
        </option>
        <option value="1947">
          1947
        </option>
        <option value="1946">
          1946
        </option>
        <option value="1945">
          1945
        </option>
        <option value="1944">
          1944
        </option>
        <option value="1943">
          1943
        </option>
        <option value="1942">
          1942
        </option>
        <option value="1941">
          1941
        </option>
        <option value="1940">
          1940
        </option>
        <option value="1939">
          1939
        </option>
        <option value="1938">
          1938
        </option>
        <option value="1937">
          1937
        </option>
        <option value="1936">
          1936
        </option>
        <option value="1935">
          1935
        </option>
        <option value="1934">
          1934
        </option>
        <option value="1933">
          1933
        </option>
        <option value="1932">
          1932
        </option>
        <option value="1931">
          1931
        </option>
        <option value="1930">
          1930
        </option>
        <option value="1929">
          1929
        </option>
        <option value="1928">
          1928
        </option>
        <option value="1927">
          1927
        </option>
        <option value="1926">
          1926
        </option>
        <option value="1925">
          1925
        </option>
        <option value="1924">
          1924
        </option>
        <option value="1923">
          1923
        </option>
        <option value="1922">
          1922
        </option>
        <option value="1921">
          1921
        </option>
        <option value="1920">
          1920
        </option>
        <option value="1919">
          1919
        </option>
        <option value="1918">
          1918
        </option>
        <option value="1917">
          1917
        </option>
        <option value="1916">
          1916
        </option>
        <option value="1915">
          1915
        </option>
        <option value="1914">
          1914
        </option>
        <option value="1913">
          1913
        </option>
        <option value="1912">
          1912
        </option>
      </select>
    </p>
    <p>
      <label for="cityOrTownOfBirth">City or Town of Birth:</label> <input type="text" id="cityOrTownOfBirth" name="cityOrTownOfBirth" size="25" />
    </p>
    <p>
      <label for="stateOrProvinceOfBirth">State or Province of Birth:<br />
      <span>(only if born in the US or Canada)</span></label> <select id="stateOrProvinceOfBirth" name="stateOrProvinceOfBirth">
        <option value="">
          Not Applicable
        </option>
        <option value="AL">
          Alabama
        </option>
        <option value="AK">
          Alaska
        </option>
        <option value="AB">
          Alberta
        </option>
        <option value="AS">
          American Samoa
        </option>
        <option value="AZ">
          Arizona
        </option>
        <option value="AR">
          Arkansas
        </option>
        <option value="BC">
          British Columbia
        </option>
        <option value="CA">
          California
        </option>
        <option value="CO">
          Colorado
        </option>
        <option value="CT">
          Connecticut
        </option>
        <option value="DE">
          Delaware
        </option>
        <option value="DC">
          District of Columbia
        </option>
        <option value="FL">
          Florida
        </option>
        <option value="GA">
          Georgia
        </option>
        <option value="GU">
          Guam
        </option>
        <option value="HI">
          Hawaii
        </option>
        <option value="ID">
          Idaho
        </option>
        <option value="IL">
          Illinois
        </option>
        <option value="IN">
          Indiana
        </option>
        <option value="IA">
          Iowa
        </option>
        <option value="KS">
          Kansas
        </option>
        <option value="KY">
          Kentucky
        </option>
        <option value="LA">
          Louisiana
        </option>
        <option value="ME">
          Maine
        </option>
        <option value="MB">
          Manitoba
        </option>
        <option value="MD">
          Maryland
        </option>
        <option value="MA">
          Massachusetts
        </option>
        <option value="MI">
          Michigan
        </option>
        <option value="MN">
          Minnesota
        </option>
        <option value="MS">
          Mississippi
        </option>
        <option value="MO">
          Missouri
        </option>
        <option value="MT">
          Montana
        </option>
        <option value="NE">
          Nebraska
        </option>
        <option value="NV">
          Nevada
        </option>
        <option value="NB">
          New Brunswick
        </option>
        <option value="NH">
          New Hampshire
        </option>
        <option value="NJ">
          New Jersey
        </option>
        <option value="NM">
          New Mexico
        </option>
        <option value="NY">
          New York
        </option>
        <option value="NL">
          Newfoundland and Labrador
        </option>
        <option value="NC">
          North Carolina
        </option>
        <option value="ND">
          North Dakota
        </option>
        <option value="MP">
          Northern Mariana Islands
        </option>
        <option value="NT">
          Northwest Territories
        </option>
        <option value="NS">
          Nova Scotia
        </option>
        <option value="NU">
          Nunavut
        </option>
        <option value="OH">
          Ohio
        </option>
        <option value="OK">
          Oklahoma
        </option>
        <option value="ON">
          Ontario
        </option>
        <option value="OR">
          Oregon
        </option>
        <option value="PA">
          Pennsylvania
        </option>
        <option value="PE">
          Prince Edward Island
        </option>
        <option value="PR">
          Puerto Rico
        </option>
        <option value="QC">
          Quebec
        </option>
        <option value="RI">
          Rhode Island
        </option>
        <option value="SK">
          Saskatchewan
        </option>
        <option value="SC">
          South Carolina
        </option>
        <option value="SD">
          South Dakota
        </option>
        <option value="TN">
          Tennessee
        </option>
        <option value="TX">
          Texas
        </option>
        <option value="UM">
          U.S. Minor Outlying Islands
        </option>
        <option value="UT">
          Utah
        </option>
        <option value="VT">
          Vermont
        </option>
        <option value="VI">
          U.S. Virgin Islands
        </option>
        <option value="VA">
          Virginia
        </option>
        <option value="WA">
          Washington
        </option>
        <option value="WV">
          West Virginia
        </option>
        <option value="WI">
          Wisconsin
        </option>
        <option value="WY">
          Wyoming
        </option>
        <option value="YT">
          Yukon Territory
        </option>
      </select>
    </p>
    <p>
      <label for="countryOfBirth">Country of Birth:</label> <select id="countryOfBirth" name="countryOfBirth">
        <option value="">
          Choose...
        </option>
        <option value="US">
          United States
        </option>
        <option value="AF">
          Afghanistan
        </option>
        <option value="AX">
          Åland Islands
        </option>
        <option value="AL">
          Albania
        </option>
        <option value="DZ">
          Algeria
        </option>
        <option value="AD">
          Andorra
        </option>
        <option value="AO">
          Angola
        </option>
        <option value="AI">
          Anguilla
        </option>
        <option value="AQ">
          Antarctica
        </option>
        <option value="AG">
          Antigua and Barbuda
        </option>
        <option value="AR">
          Argentina
        </option>
        <option value="AM">
          Armenia
        </option>
        <option value="AW">
          Aruba
        </option>
        <option value="AU">
          Australia
        </option>
        <option value="AT">
          Austria
        </option>
        <option value="AZ">
          Azerbaijan
        </option>
        <option value="BS">
          Bahamas
        </option>
        <option value="BH">
          Bahrain
        </option>
        <option value="BD">
          Bangladesh
        </option>
        <option value="BB">
          Barbados
        </option>
        <option value="BY">
          Belarus
        </option>
        <option value="BE">
          Belgium
        </option>
        <option value="BZ">
          Belize
        </option>
        <option value="BJ">
          Benin
        </option>
        <option value="BM">
          Bermuda
        </option>
        <option value="BT">
          Bhutan
        </option>
        <option value="BO">
          Bolivia
        </option>
        <option value="BA">
          Bosnia and Herzogovina
        </option>
        <option value="BW">
          Botswana
        </option>
        <option value="BV">
          Bouvet Island
        </option>
        <option value="BR">
          Brazil
        </option>
        <option value="BN">
          Brunei Darussalam
        </option>
        <option value="BG">
          Bulgaria
        </option>
        <option value="BF">
          Burkina Faso
        </option>
        <option value="BI">
          Burundi
        </option>
        <option value="KH">
          Cambodia
        </option>
        <option value="CM">
          Cameroon
        </option>
        <option value="CA">
          Canada
        </option>
        <option value="CV">
          Cape Verde
        </option>
        <option value="KY">
          Cayman Islands
        </option>
        <option value="CF">
          Central African Republic
        </option>
        <option value="TD">
          Chad
        </option>
        <option value="CL">
          Chile
        </option>
        <option value="CN">
          People's Republic of China
        </option>
        <option value="CX">
          Christmas Island
        </option>
        <option value="CC">
          Cocos (Keeling) Islands
        </option>
        <option value="CO">
          Colombia
        </option>
        <option value="KM">
          Comoros
        </option>
        <option value="CD">
          Democratic Republic of the Congo
        </option>
        <option value="CG">
          Republic of the Congo
        </option>
        <option value="CK">
          Cook Islands
        </option>
        <option value="CR">
          Costa Rica
        </option>
        <option value="CI">
          Côte d'Ivoire
        </option>
        <option value="HR">
          Croatia
        </option>
        <option value="CU">
          Cuba
        </option>
        <option value="CY">
          Cyprus
        </option>
        <option value="CZ">
          Czech Republic
        </option>
        <option value="DK">
          Denmark
        </option>
        <option value="DJ">
          Djibouti
        </option>
        <option value="DM">
          Dominica
        </option>
        <option value="DO">
          Dominican Republic
        </option>
        <option value="EC">
          Ecuador
        </option>
        <option value="EG">
          Egypt
        </option>
        <option value="SV">
          El Salvador
        </option>
        <option value="GQ">
          Equatorial Guinea
        </option>
        <option value="ER">
          Eritrea
        </option>
        <option value="EE">
          Estonia
        </option>
        <option value="ET">
          Ethiopia
        </option>
        <option value="FK">
          Falklands Islands (Malvinas)
        </option>
        <option value="FO">
          Faroe Islands
        </option>
        <option value="FJ">
          Fiji
        </option>
        <option value="FI">
          Finland
        </option>
        <option value="FR">
          France
        </option>
        <option value="GA">
          Gabon
        </option>
        <option value="GM">
          Gambia
        </option>
        <option value="GE">
          Georgia
        </option>
        <option value="DE">
          Germany
        </option>
        <option value="GH">
          Ghana
        </option>
        <option value="GI">
          Gibraltar
        </option>
        <option value="GR">
          Greece
        </option>
        <option value="GL">
          Greenland
        </option>
        <option value="GD">
          Grenada
        </option>
        <option value="GP">
          Guadeloupe
        </option>
        <option value="GT">
          Guatemala
        </option>
        <option value="GF">
          French Guiana
        </option>
        <option value="GN">
          Guinea
        </option>
        <option value="GW">
          Guinea-Bissau
        </option>
        <option value="GY">
          Guyana
        </option>
        <option value="HT">
          Haïti
        </option>
        <option value="HM">
          Heard Island and McDonald Islands
        </option>
        <option value="HN">
          Honduras
        </option>
        <option value="HK">
          Hong Kong
        </option>
        <option value="HU">
          Hungary
        </option>
        <option value="IS">
          Iceland
        </option>
        <option value="IN">
          India
        </option>
        <option value="IO">
          British Indian Ocean Territory
        </option>
        <option value="ID">
          Indonesia
        </option>
        <option value="IR">
          Iran
        </option>
        <option value="IQ">
          Iraq
        </option>
        <option value="IE">
          Ireland
        </option>
        <option value="IL">
          Israel
        </option>
        <option value="IT">
          Italy
        </option>
        <option value="JM">
          Jamaica
        </option>
        <option value="JP">
          Japan
        </option>
        <option value="JO">
          Jordan
        </option>
        <option value="KZ">
          Kazakhstan
        </option>
        <option value="KE">
          Kenya
        </option>
        <option value="KI">
          Kiribati
        </option>
        <option value="KP">
          North Korea
        </option>
        <option value="KR">
          South Korea
        </option>
        <option value="KW">
          Kuwait
        </option>
        <option value="KG">
          Kyrgyzstan
        </option>
        <option value="LA">
          Laos
        </option>
        <option value="LV">
          Latvia
        </option>
        <option value="LB">
          Lebanon
        </option>
        <option value="LS">
          Lesotho
        </option>
        <option value="LR">
          Liberia
        </option>
        <option value="LY">
          Libya
        </option>
        <option value="LI">
          Liechtenstein
        </option>
        <option value="LT">
          Lithuania
        </option>
        <option value="LU">
          Luxembourg
        </option>
        <option value="MK">
          Macedonia
        </option>
        <option value="MG">
          Madagascar
        </option>
        <option value="MW">
          Malawi
        </option>
        <option value="MY">
          Malaysia
        </option>
        <option value="MV">
          Maldives
        </option>
        <option value="ML">
          Mali
        </option>
        <option value="MT">
          Malta
        </option>
        <option value="MH">
          Marshall Islands
        </option>
        <option value="MQ">
          Martinique
        </option>
        <option value="MR">
          Mauritania
        </option>
        <option value="MU">
          Mauritius
        </option>
        <option value="YT">
          Mayotte
        </option>
        <option value="MX">
          Mexico
        </option>
        <option value="FM">
          Federated States of Micronesia
        </option>
        <option value="MD">
          Moldova
        </option>
        <option value="MC">
          Monaco
        </option>
        <option value="MS">
          Montserrat
        </option>
        <option value="MA">
          Morocco
        </option>
        <option value="MZ">
          Mozambique
        </option>
        <option value="MM">
          Myanmar
        </option>
        <option value="MO">
          Macao
        </option>
        <option value="MN">
          Mongolia
        </option>
        <option value="NA">
          Namibia
        </option>
        <option value="NR">
          Nauru
        </option>
        <option value="NP">
          Nepal
        </option>
        <option value="NL">
          Netherlands
        </option>
        <option value="AN">
          Netherlands Antilles
        </option>
        <option value="NC">
          New Caledonia
        </option>
        <option value="NZ">
          New Zealand
        </option>
        <option value="NI">
          Nicaragua
        </option>
        <option value="NE">
          Niger
        </option>
        <option value="NG">
          Nigeria
        </option>
        <option value="NU">
          Niue
        </option>
        <option value="NF">
          Norfolk Island
        </option>
        <option value="NO">
          Norway
        </option>
        <option value="OM">
          Oman
        </option>
        <option value="PK">
          Pakistan
        </option>
        <option value="PW">
          Palau
        </option>
        <option value="PS">
          Palestinian Territory
        </option>
        <option value="PA">
          Panama
        </option>
        <option value="PG">
          Papua New Guinea
        </option>
        <option value="PY">
          Paraguay
        </option>
        <option value="PE">
          Peru
        </option>
        <option value="PH">
          Philippines
        </option>
        <option value="PN">
          Pitcairn
        </option>
        <option value="PL">
          Poland
        </option>
        <option value="PF">
          French Polynesia
        </option>
        <option value="PT">
          Portugal
        </option>
        <option value="QA">
          Qatar
        </option>
        <option value="RE">
          Réunion
        </option>
        <option value="RO">
          Romania
        </option>
        <option value="RU">
          Russia
        </option>
        <option value="RW">
          Rwanda
        </option>
        <option value="SH">
          Saint Helena
        </option>
        <option value="KN">
          Saint Kitts and Nevis
        </option>
        <option value="LC">
          Saint Lucia
        </option>
        <option value="PM">
          Saint Pierre and Miquelon
        </option>
        <option value="VC">
          Saint Vincent and the Grenadines
        </option>
        <option value="WS">
          Samoa
        </option>
        <option value="SM">
          San Marino
        </option>
        <option value="ST">
          Sao Tome and Principe
        </option>
        <option value="SA">
          Saudi Arabia
        </option>
        <option value="SN">
          Senegal
        </option>
        <option value="CS">
          Serbia and Montenegro
        </option>
        <option value="SC">
          Seychelles
        </option>
        <option value="SL">
          Sierra Leone
        </option>
        <option value="SG">
          Singapore
        </option>
        <option value="SK">
          Slovakia
        </option>
        <option value="SI">
          Slovenia
        </option>
        <option value="SB">
          Solomon Islands
        </option>
        <option value="SO">
          Somalia
        </option>
        <option value="ZA">
          South Africa
        </option>
        <option value="GS">
          South Georgia and the South Sandwich Islands
        </option>
        <option value="TF">
          French Southern Territories
        </option>
        <option value="ES">
          Spain
        </option>
        <option value="LK">
          Sri Lanka
        </option>
        <option value="SD">
          Sudan
        </option>
        <option value="SR">
          Suriname
        </option>
        <option value="SJ">
          Svalbard and Jan Mayen
        </option>
        <option value="SZ">
          Swaziland
        </option>
        <option value="SE">
          Sweden
        </option>
        <option value="CH">
          Switzerland
        </option>
        <option value="SY">
          Syria
        </option>
        <option value="TW">
          Taiwan
        </option>
        <option value="TJ">
          Tajikistan
        </option>
        <option value="TZ">
          Tanzania
        </option>
        <option value="TH">
          Thailand
        </option>
        <option value="TL">
          Timor-Leste (East Timor)
        </option>
        <option value="TG">
          Togo
        </option>
        <option value="TK">
          Tokelau
        </option>
        <option value="TO">
          Tonga
        </option>
        <option value="TT">
          Trinidad and Tobago
        </option>
        <option value="TN">
          Tunisia
        </option>
        <option value="TR">
          Turkey
        </option>
        <option value="TM">
          Turkmenistan
        </option>
        <option value="TC">
          Turks and Caicos Islands
        </option>
        <option value="TV">
          Tuvalu
        </option>
        <option value="UG">
          Uganda
        </option>
        <option value="UA">
          Ukraine
        </option>
        <option value="AE">
          United Arab Emirates
        </option>
        <option value="GB">
          United Kingdom
        </option>
        <option value="UY">
          Uruguay
        </option>
        <option value="UZ">
          Uzbekistan
        </option>
        <option value="VU">
          Vanuatu
        </option>
        <option value="VA">
          Vatican
        </option>
        <option value="VE">
          Venezuela
        </option>
        <option value="VN">
          Vietnam
        </option>
        <option value="VG">
          British Virgin Islands
        </option>
        <option value="WF">
          Wallis and Futuna
        </option>
        <option value="EH">
          Western Sahara
        </option>
        <option value="YE">
          Yemen
        </option>
        <option value="ZM">
          Zambia
        </option>
        <option value="ZW">
          Zaïre
        </option>
      </select>
    </p>
    <p>
      <label for="studentSSNa">U.S. Social Security Number:<br />
      <span>(<a href="javascript:newWin('why_enter_ssn.html')">Why do we ask for your SSN?</a>)</span></label> <input type="text" id="studentSSNa" name="studentSSNa" size="3" maxlength="3" /> <span>&nbsp;-&nbsp;</span> <input type="text" id="studentSSNb" name="studentSSNb" size="2" maxlength="2" /> <span>&nbsp;-&nbsp;</span> <input type="text" id="studentSSNc" name="studentSSNc" size="4" maxlength="4" />
    </p>
    <p>
      <label for="idCardNumber">UT Austin ID Card Number:<br /></label> <input type="text" id="idCardNumber" name="idCardNumber" size="25" /> <span>(The 16-digit number on the front of your UT Austin ID card, if you have one).</span>
    </p>
    <p>
      <label for="emailAddress">E-mail Address:</label> <input type="text" id="emailAddress" name="emailAddress" size="25" /> <span>(Use an e-mail account you will have access to several months from now. <a href="javascript:newWin('why_enter_email.html')">Why?</a>)</span>
    </p>
    <p>
      <label for="emailAddressVerify">Verify Your E-mail Address:</label> <input type="text" id="emailAddressVerify" name="emailAddressVerify" size="25" />
    </p>
  </fieldset>
  <p>
    <a id="backSubmit" href="?back&amp;qwicap-page-id=D41F428A46D78104" name="backSubmit">Back</a> <a href="?cancel&amp;qwicap-page-id=D41F428A46D78104">Cancel</a> <input type="hidden" name="continue" value="Continue" /> <input type="submit" name="continue" value="Continue" />
  </p>
</form>
